Economic Impact of the
Related Health Sectors of
Goodhue County
July 22, 2004
Produced by Rural Health Resource Center, Minnesota Center for Rural Health
for the Office of Rural Health and Primary Care,
Minnesota Department of Health
Produced by the Rural Health Resource Center, Minnesota Center for Rural Health
for the Office of Rural Health and Primary Care, Minnesota Department of Health
1
The Background of Rural Health Works
The healthcare industry has a tremendous economic impact on a community and also serves to
improve quality of life. This is especially true with healthcare facilities such as hospitals, clinics,
and nursing homes. These facilities not only employ a number of people and have large
payrolls, they purchase goods and services from other local businesses. Healthcare employees
also shop at local businesses and pay taxes. A strong healthcare sector promotes job growth
within other industries and attracts retirees and young families.
The Rural Health Works program offered by the Office of Rural Health and Primary Care,
Minnesota Department of Health helps demonstrate the economic importance of the healthcare
sector. It is often the largest rural county employer and frequently is directly responsible for 10
to 15% of jobs. This report measures the economic impact for Goodhue County in terms of
direct healthcare jobs and income. It also estimates the secondary impact of the healthcare
sector on the economy.
The Methodology of an Economic Impact Study
The healthcare sector includes five components:
• Hospitals
• Doctors and Dentists (includes chiropractors, optometrists)
• Nursing and Protective Care (nursing and group homes)
• Other Medical and Health Services (includes home health care, veterinarians,
rehabilitation, and the county health departments)
• Pharmacies
Figure 1. Community Economic System
The actual employment, income, and sales of
Inputs
$
goods and services provided in the healthcare
industry are key aspects of the industry’s overall
Products
$
Basic
local economic impact. Some of the goods and
Industry
services are sold to buyers outside of the
community which creates a flow of dollars into
the community (Figure 1). To produce these
$ $
Inputs
Labor
goods and services for “export” outside the
community, the basic industry purchases inputs
Goods &
from outside the community, labor from the
Services
households and inputs from service industries
located in the community. The flow of labor,
Household
Service
$
goods and services in the community is
completed when households use their earnings to
purchase goods and services from the
community’s service industries such as
$
$
healthcare.
This theory can be demonstrated by considering the impact of a hospital closing. The services
section will no longer pay employees and dollars going to households will stop. Likewise, the
hospital will not purchase goods from other businesses and the dollar flow to other businesses
will stop. This decreases income in the "households" segment of the economy. Since earnings
would decrease, households decrease their purchases of goods and services from businesses
within the "services" segment of the economy. This, in turn, decreases these businesses'
Produced by the Rural Health Resource Center, Minnesota Center for Rural Health
for the Office of Rural Health and Primary Care, Minnesota Department of Health
2
purchases of labor and inputs. Thus, the change in the economic base works its way throughout
the entire local economy.
The total impact of a change in the economy consists of direct, indirect, and induced impacts.
Direct impacts are the changes in the activities of the impacting industry, such as the opening
of a new hospital service. The impacting business, such as a hospital birthing center, changes
its purchases of inputs as a result of the direct impact. This produces an indirect impact in the
business sectors. Both the direct and indirect impacts change the flow of dollars to the
community's households. The households alter their consumption accordingly. The effect this
change in household consumption has upon businesses in a community is referred to as an
induced impact (Figure 2).
A measure is needed that yields the effects created by an increase or decrease in economic
activity. In economics, this measure is called the multiplier effect. Employment and income
multipliers for the area have been calculated using the IMPLAN model. IMPLAN was developed
by the U.S. Forest Service and is a model that allows for development of county multipliersa. A
Type SAM multiplier is used in this report. It is defined as the ratio between direct employment
or that employment used by the industry initially experiencing a change in final demand and the
direct, indirect, and induced employment. For example, an employment multiplier of 2.0
indicates that if one job is created by a new industry, one other job is created in other sectors
due to business (indirect) and household (induced) spending.
Figure 2. The Linkages of the Healthcare Sector
Trade
Health Care
Sector
Employer &
Purchaser
“backward
linkages”
Industry
Service Provider
“forward
linkages”
Employee
Households
Retirees
Services
a
For complete details of the IMPLAN model and an explanation of different types of IMPLAN multipliers, see [1].
Type SAM multipliers are calculated using a “social accounting matrix” methodology that accounts for commuting,
social security tax payments as well as household income taxes and savings. Type SAM multipliers separate the
effects of market income such as employment payrolls, from government expenditures such as social security
payments. Thus, Type SAM multipliers give estimates that are more accurate than earlier versions described in
the literature as Type II and Type III multipliers.
Produced by the Rural Health Resource Center, Minnesota Center for Rural Health
for the Office of Rural Health and Primary Care, Minnesota Department of Health
3
The Potential
A factor important to the success of rural economic development is job creation. Nationally,
employment in healthcare services increased by 28 percent from 1990 to 2000, and by more
than 200 percent since 1970 (Table 1). It is also important to note that the health sector is a
growing sector. Table 1 illustrates how health services, as a share of gross domestic product
(GDP), have increased over time. In 1970, Americans spent $73.1 billion on health are, which
accounted for 7.0 percent of the GDP. In 2000, healthcare costs ballooned to nearly $1.3
trillion, or about 13.2 percent of the GDP. Capturing this economic growth can only help a rural
community.
Table 1. National Health Expenditures and Employment Data
1970-2000
Expenditures Employment in
Per Capita
Total
Health Sector
as a Percent
Expenditures Expenditures
Year
(million Jobs)
of GDP
($)
($ Billion)
1970
$73
$348
7.0
3,053
1980
246
1,067
8.8
5,278
1990
696
2,736
12.0
7,814
2000
1,300
4,637
13.2
10,103
Annual
Increase in
Employment
5.6%
4.0%
1.3%
SOURCE: Centers for Medicare and Medicaid Services, National Health Expenditures and Selected Economic
Indicators, <cms.hhs.gov/statistics/nhc/projections-2001/t1.asp>, Bureau of Labor Statistics (BLS),
<stats.bls.gov/data/home.htm>.
So, how can your community take advantage of the economic benefits of healthcare? Do you
have a strong healthcare system that is well supported by the community, or are the healthcare
dollars from your community “outmigrating” to the next largest community? Do you want to
retain the businesses and residents in your area, while attracting new ones to expand your
economic base? Active participation in the healthcare decision-making process in your
community, by community citizens and leaders can make a huge difference and, hopefully, reap
economic and health rewards for the entire community. The amount of this health spending
retained by a rural community depends on several factors and may have a potentially large and
immediate impact on the local economy, the number of jobs created, and the number of new
residents moving into the community. The secondary impact of increased healthcare spending,
such as higher retail sales in non-health areas or new housing starts, may also have a sizeable
impact on the community.
How can you determine if healthcare is important or should be important to your community’s
economy? The first step is to determine what types of health services are used in your
community, and what the expenditures are for those services. The first column of Table 2
shows the 2001 Minnesota per capita expenditures by major categories of health care. The
estimated 2000 population of Goodhue County is 44,127. Column four multiplies the per capita
expenditures by that estimated service area population to arrive at an estimated economic
impact of providing those services in Goodhue County: $129,027,348. (See Appendix A for a
detailed description of how these numbers were derived.)
Produced by the Rural Health Resource Center, Minnesota Center for Rural Health
for the Office of Rural Health and Primary Care, Minnesota Department of Health
4
Table 2. Estimated Potential Personal Primary Care Expenditures for the Goodhue Health
Sectors
Health Services
Hospital Care
Physician & Other
Professional Services
Home Health Care
Nursing Home Care
Dental Services
Drugs & Other NonDurables
Medical Durables
Other Personal Healthcare
Total
2001
Minnesota
Per Capita a
$1,329
61% 2
$811
Market Area
Potential
Expenditures b
$35,786,997
1,428
75% 3
1,071
47,260,017
94
439
229
100% 4
100% 5
75% 3
94
439
172
4,147,938
19,371,753
7,589,844
449
75% 3
337
14,870,799
74
182
$4,225
-- 3
-- 3
69%
Percent
Primary Care
Primary Care
Per Capita
----$2,924 $129,027,348
SOURCE: Centers for Medicare and Medicaid Services <cms.hhs.gov/statistics/nhe/default.asp>
Numbered footnotes are presented in Appendix A.
a Per capita expenditures are 1998 data adjusted for inflation using the GDP implicit price deflator.
b Based on per capita amounts and a market area population estimate of (c) people.
By comparing the potential impact with actual local data, your community can determine how
much health care is provided locally, and if there is an opportunity to expand these offerings,
thus bringing more health dollars into the local economy. For example, the hospital will have an
annual estimate of total billings. If this figure is below the potential, there may be room to
expand hospital services and retain more dollars in your community. An example of a service
that can be provided completely within the service area is nursing homes. One simple way to
determine if local needs are being met is to determine if there is are waiting lists at existing
facilities or if local residents are using facilities outside the service area. If residents are going
outside the service area, then there is a potential to expand locally.
Every health care service provided locally benefits the rural community twice—first, it improves
people’s health, and second, it improves the health of the local economy. Another perspective
is the economic potential of the healthcare industry from the growth in health-related
occupations. Statewide, healthcare represented 204,940 jobs in 2003, or about eight percent of
all jobs in the state. Health-related jobs are expected to increase 17% percent by 2010. When
both employment increases and replacements are considered, total openings through 2010 are
expected to be 28,714. Healthcare jobs are made up of roughly two-thirds professional and
technician positions, and one-third services and related occupations. Employment projections
are not available on a county basis, but for the Southeast Planning Region healthcare
represented 19,773 jobs in 2000 and is expected to increase 14% by 2010.
The People of Goodhue County
The population of Goodhue County was 44,127 in 2000. The county has experienced a positive
population growth of 7.9% (compared to 12.4% statewide) during 1990 – 2000 (Table 3).
County population is projected to increase through 2015. A significant increase occurred in the
county’s Hispanic and American Indian population during the last decade. White (non-Hispanic)
Produced by the Rural Health Resource Center, Minnesota Center for Rural Health
for the Office of Rural Health and Primary Care, Minnesota Department of Health
5
people still represented the great majority of county population in 2000, while 2% of the
population was Hispanic and American Indian in 2000.
Table 4. Selected Demographic Data for Goodhue County and the State of Minnesota
Selected Item
Population Change
(1980-1990)
(1990-2000)
Population Projections:
Goodhue County
38,749→ 40,649
40,649→ 44,127
Year 2005 = 45,540
Year 2010 = 47,140
Year 2015 = 48,820
Population by Race (2000)
White
American Indian 1
Black
Other 2
Two or more races 3
Hispanic ethnic background 4
42,613
434
280
232
305
473
County
Percent
State
Percent
+4.0
+7.9
+7.4
+12.4
95.9
1.0
0.7
0.6
0.7
1.1
89.4
1.1
3.5
4.2
1.7
2.9
SOURCE: U.S. Census Bureau, 2000 data available from the Minnesota Planning Agency
<www.mnplan.state.mn.us/demography/index.html>. The estimates for 2005-2015 are from the
Minnesota State Demographer’s Office.
1
2
3
4
Native American includes American Indian and Alaska Natives
Other defined as: Asian Americans, Native Hawaiian, Pacific Islander and all others.
Two or more races indicate a person is included in more than one race group.
Hispanic population is not a race group but rather a description of ethnic origin; Hispanics are included in all four-race groups.
In addition, the Goodhue County population is older than the State of Minnesota, with the
elderly (aged 60+) representing 19.0% compared to 12.6% statewide (Figure 3).
Figure 3. Population by Age Group for Goodhue County and Minnesota
30.0%
% of Population
25.0%
20.0%
15.0%
(b) County
Minnesota
10.0%
5.0%
0.0%
0-19 20-24 25-34 35-44 45-54 55-59 60+
Age Group
Produced by the Rural Health Resource Center, Minnesota Center for Rural Health
for the Office of Rural Health and Primary Care, Minnesota Department of Health
6
Table 5 shows economic indicators for Goodhue County and Statewide. The average per capita
income in Goodhue County was $27,650 compared to $31,935 for Minnesota. An estimated
5.7% of Goodhue’s County’s population was below the poverty rate compared to the state rate
of 6.9%. The data indicates that 12.6% of total personal income for Goodhue County came
from transfer payments (income subsidy such as Social Security, Medicare, or Medicaid).
Table 5. Economic Indicators for Goodhue County, the State of Minnesota and the Nation
Indicator
County
State
Nation
$1.2 billion
$157.4 billion
$8.31 trillion
$27,650
$31,935
$29,469
24,927
2,814,357
135 million
Unemployment (2003)
1277
129,535
7.9 million
Unemployment Rate (2003)
5.3%
4.5%
5.4%
Poverty Rate (2001)
5.7%
6.9%
11.5%
$152,139,00
$16.8 billion
$1.07 trillion
12.6%
10.7%
12.9%
Total Personal Income (2000)
Per Capita Income (2000)
Civilian Labor Force (2001) a
Transfer Dollars (2000)
Transfer Dollars as percentage of
Total Personal Income (2000)
SOURCE: U.S. Bureau of Economic Analysis <www.bea.doc.gov/bea/regional/reis/>, Bureau of Labor Statistics
<www.bls.gov/data/home.htm>, and Census Bureau www.census.gov/hhes/www/poverty.html
a Labor force estimates are from the U.S. Bureau of Labor Statistics Current Population Survey.
Employed persons holding more than one job are only counted once.
The Place
Goodhue County is located in Southeastern Minnesota. The county has a total of 758 square
miles with a population density of 58.2 people per square mile (Minnesota 61.8 per square
mile). There are 16,983 households. Goodhue’s service area includes surrounding cities and
townships primarily in Goodhue County. Figure 4. Goodhue Service Area
Produced by the Rural Health Resource Center, Minnesota Center for Rural Health
for the Office of Rural Health and Primary Care, Minnesota Department of Health
7
Employment data by industry for Goodhue County is presented in Figure 5; data is for 2000
from the Bureau of Economic Analysis, Regional Economic Information System. Total
employment in the county was 24,927 in 2003. Healthcare services accounted for 11 % of the
employment in Goodhue County. The industry sectors with the largest employment are nonhealthcare services, manufacturing, and retail trade which comprise the largest share of the
Goodhue County economic base.
Figure 5. Employment by Sector for Goodhue County
Education
7%
Hospital
5%
Farm
5%
Construction
7%
Other Medical
6%
Farm
Construction
Manufacturing
Government
3%
Manufacturing
20%
Wholesale Trade
Transportation
Retail Trade
Financial/Realty
Non-Healthcare Services
Non-Healthcare Services
22%
Wholesale Trade
3%
Transportation
6%
Financial/Realty
5%
Government
Other Medical
Hospital
Education
Retail Trade
11%
Employment and payroll are the important direct economic activities created in Goodhue County
from the health sector. The total health sector in the County employs 2483 employees and has
an estimated 2003 payroll of $88,166,573 (Table 6). The health sector in Goodhue County has
3 hospitals, 8 physician offices, 16 dentists, 7 nursing homes, 11 home care agencies, and 13
pharmacies and 3 assisted living facilities. The three hospitals employ 1174 people with an
annual payroll of $57,298,032. Services at the three hospitals include home care services,
mental health, nursing home, rehabilitation services, surgery and medicine. It should be noted
that many rural communities have a large number of elderly and farmers that often retire in the
towns. Thus, Nursing and Protective Care facilities are an important component of the health
sector. The health sector purchases goods and services from other sectors of the economy,
totaling $102,273,224 together with payroll, health sector expenditures amounted to
$190,439,797 in 2003.
Produced by the Rural Health Resource Center, Minnesota Center for Rural Health
for the Office of Rural Health and Primary Care, Minnesota Department of Health
8
Table 6. Direct Economic Activities of the Health Sector in the (a)
Service Area and Goodhue County, Minnesota, 2003
Component
Estimated
Employees
Estimated
Expenditures
Estimated Payroll
Hospital Fairview Red Wing, Cannon Falls Community Hospital,
Lake City Medical Center Mayo Health System
1174
$57,298,032
185
6,143,000
648
14,854,000
Other Medical & Health Services
368
7,996,000
Pharmacies
108
1,875,541
2483
$88,166,573
Doctors and Dentists
(Includes physician offices,
plus chiropractors, optometrists, and visiting specialists)
Nursing & Protective Care
(Nursing homes and supervised
living facilities)
TOTAL EMPLOYEES AND PAYROLL
Expenditures for Goods and Services
other than Payroll
TOTAL EXPENDITURES
$102,273,224
$190,439,797
SOURCE: From local survey and 2000 IMPLAN data estimated from U.S. Census Bureau County Business Patterns
and U.S. Bureau of Economic Analysis reports, indexed to 2003 dollars.
The Impact
The employment and income impacts for Goodhue County have been estimated by calculating
multipliers using a software system called IMPLAN. A multiplier is the ratio between actual
employment or income from one industry and the sum of its direct, indirect, and induced
effects, defined here as the total impact on the rest of the local economy. Table 7 summarizes
the industry employment impact and income impact that result from the presence of the health
care industry in Goodhue County.
Produced by the Rural Health Resource Center, Minnesota Center for Rural Health
for the Office of Rural Health and Primary Care, Minnesota Department of Health
9
Table 7. Economic Impact of the Health Sector on Employment and Income in Goodhue
County, Minnesota, 2003
(1)
(2)
(3)
(4)
(5)
(6)
Health Sector
Component
Hospitals
Doctors &
Dentists
Nursing &
Protective Care
Other Health
Services
Pharmacies and
Related
TOTALS
Health-Related as
% of Goodhue
County Total
Expenditures
Other Than
Payroll
TOTAL
EXPENDITURES
% of Goodhue
County Total
Economic Output
Estimated
Expenditures
Type SAM
Multipliera
(7)
Employment
Type SAM
Multipliera
Employment
Impact
Income
Impact
1174
1.42
1667
$57,298,032
1.22
$69,903,599
185
1.43
264
6,143,000
1.33
8,170,190
648
1.20
777
14,854,000
1.20
17,824,800
134
1.27
184
7,996,000
1.28
10,234,880
108
1.16
125
1,875,541
1.18
2,213,138
2483
2968
$88,166,573
$108,346,607
10%
11.9%
$102,273,224
$124,773,322
$190,439,797
$233,119,929
7.4%
9%
SOURCE: 2000 IMPLAN Data Base indexed to 2003 dollars; 2000 Minnesota County Business Patterns, U.S. Bureau of
Economic Analysis, Regional Economic Information System <www.bea.doc.gov/bea/regional/reis/>.
a A Type SAM employment multiplier is calculated using the formula: (direct employment in these industries +
employment generated indirectly in input supplier firms + additional employment induced by the employees’
consumer spending)/(direct employment). A type SAM income multiplier is calculated in a similar fashion.
The total employment impact of the healthcare sector in Goodhue County is 2483 jobs.
• There are approximately 2483 actual jobs in the healthcare industry in Goodhue County.
• Approximately 485 additional jobs are supported in Goodhue County by the healthcare
sector through the multiplier effect.
• The combined effect represents 11.9% of Goodhue County’s total employment.
The total income impact of the healthcare industry in Goodhue’s County is $108.3 million.
• The health care industry provides approximately $88.1 million in income annually in
Goodhue County.
• Approximately $20.2 million in additional income in Goodhue County is supported by the
healthcare sector through the multiplier effect.
• The $102.2 million spent in the healthcare sector of Goodhue County has created
another $22.5 million of spending in other sectors of the County’s economy. Therefore,
the combined effect represents 9% of the county’s total economic output.
Produced by the Rural Health Resource Center, Minnesota Center for Rural Health
for the Office of Rural Health and Primary Care, Minnesota Department of Health
10
The Next Steps
The economic impact of the health sector upon the economy of Goodhue County and the rest of
the surrounding service area is significant. The health sector employs a large number of
residents, similar to a large industrial firm. The secondary impact occurring in the community is
quite large and measures the total impact of the health sector. If the health sector increases or
decreases in size, the medical health of the community, and the economic health of the
community are greatly affected. For the retention and attraction of industrial firms, businesses,
and retirees, it is crucial that the area have a quality health sector. Often overlooked is the fact
that a prosperous health sector contributes to the economic health of the community.
•
•
•
•
10 new jobs in the healthcare sector creates 3.5 non-healthcare jobs in Goodhue County
$100 of income earned in the health sector leads to another $25 earned in other sectors
of the County’s economy
One dollar spent on healthcare, leads to another $.25 spent in other sectors
The overall economic impact due to healthcare in Goodhue County is estimated at
$233.1 million
Benefits of Rural Health Works
The Rural Health Works program is designed to increase awareness of the vital economic role
health care plays in rural communities. Promotion of the study may help increase support for
local healthcare services by local residents and businesses. Moreover it may be used as a
recruitment tool for healthcare providers and serve to develop healthcare workforce
partnerships between educational institutions, workforce centers, the local chamber of
commerce and the healthcare industry.
In summary, the health sector is vitally important as a community employer and important to
the community's economy. The health sector definitely employs a large number of residents.
The health sector and the employees in the health sector purchase a significant amount of
goods and services from businesses in Goodhue County and the rest of the service area. These
impacts are secondary benefits to the economy. Moreover, the health sector is a provider of
essential services to an aging population in Goodhue County and is a source of expanding
career opportunities.
Produced by the Rural Health Resource Center, Minnesota Center for Rural Health
for the Office of Rural Health and Primary Care, Minnesota Department of Health
11
Appendix A
Footnotes for Table 2
The Centers for Medicare and Medicaid (CMS) develops the per capita expenditure for health
care annually. The data are secondary sources that are tabulated for other purposes. National
health expenditures reported here include spending by type of expenditure (i.e., hospital care,
physician care, dental care, and other professional care; home health; drugs and other medical
non-durables; vision products and other medical durables; nursing home care and other
personal health expenditures. Not included are non-personal expenditures for such items as
public health, research, construction of medical facilities and administration). The primary care
percentages are adapted from an Oklahoma study [2].
1
2 This estimate is extrapolation from Kentucky’s experience. Kentucky’s Medicaid program offers
a wider range of services than required by Medicaid. To restrain Medicaid cost increases,
Kentucky established a primary care gatekeeper program several years ago. This program is
thought to have an impact with respect to appropriate utilization of care, but is not felt to be
fully effective. Kentucky Medicaid eligible may use healthcare more appropriately than
individuals insured through commercial insurance plans. A 1996 study compared local to nonlocal use by 300,500 Medicaid eligible who reside in 49 rural counties in Southeast Kentucky.
The aggregate of the 49 counties retained 61% of all hospital expenditures. Measuring by
expenditure is important, particularly in hospital care, because tertiary care is far more
expensive. This percentage was applied to Table 2. Other examples of hospital expenditure
retention include a large (50,000) rural county in the western part of Kentucky with two large
hospitals. These hospitals reported an aggregate retention of 96% of all inpatient admissions
(expenditure data were not available). A small, 71-bed hospital in a county with 17,000 people
retained 64% of all admissions. A very large 288-bed hospital in a county of 30,000 retained
77% of all admissions. This county has as a large sub-specialty complement of physicians.
The federal Bureau of Primary Health Care (BPHC) required that applicants for
Community/Migrant Health Centers (C/MHC) grants (330 clinics) develop a needs assessment to
justify staffing of the clinic with physicians, midlevel, dentists, optometrists, pharmacists, and
other providers. To help support the needs assessment and assure consistency in needs
assessment assumptions, BPHC provided a formula, based on age and sex of the service area
population that derived the total number of all ambulatory care visits. The formula estimates
that 75% of all ambulatory care visits would be to primary care physicians. Note that these
estimates use visits as the denominator. The problem with applying the use rates in Table 2 to
estimate expenditure retention is that a visit to a sub-specialist costs more than a visit to the
primary care provider. However, the difference in expenditure is not as great as comparing a
hospital stay for a simple appendectomy with a hospital stay for open-heart surgery. Although it
may overstate the potential expenditure, the BPHC rate was applied here.
3
4
Home health care is low technology care and can easily be offered by rural-based providers.
5 Nursing home care is low technology care, yet very expensive. In Kentucky, the average
annual cost per patient excluding physician services and drugs is $35,000 per patient year.
Nursing home costs may vary significantly by state. Nursing home care can easily be provided
in any rural community.
Produced by the Rural Health Resource Center, Minnesota Center for Rural Health
for the Office of Rural Health and Primary Care, Minnesota Department of Health
12
References
[1] Minnesota IMPLAN Group, Inc. IMPLAN Professional Version 2.0 User’s Guide, 1725 Tower
Drive West, Suite 140, Stillwater, Minnesota 55082, ,www.implan.com.>
[2] Eilrich, F. C. St. Clair and G.A. Doeksen. The Importance of the Health Care Sector on the
Economy of Atoka County, Oklahoma, Rural Development, Oklahoma Cooperative Extension
Service, Oklahoma State University, Stillwater, Oklahoma.
Produced by the Rural Health Resource Center, Minnesota Center for Rural Health
for the Office of Rural Health and Primary Care, Minnesota Department of Health
13